197609766-4-28-2023-31-AS-TSMH-CRBVGB-20230428162517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609766
Report Date: 04/28/2023
Date Signed: 04/28/2023 04:25:31 PM

Document Has Been Signed on 04/28/2023 04:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HORIZON ASSISTED LIVING FACILITY		FACILITY NUMBER:	197609766
ADMINISTRATOR:	SONA GEVORKYAN		FACILITY TYPE:	740
ADDRESS:	9708 VALJEAN AVE		TELEPHONE:	(310) 720-4551
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 6	DATE:	04/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Sona Gervorkyan		TIME COMPLETED:	04:27 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility 11:55 am. LPA disclosed to the administrator the purpose of the visit. LPA conducted a tour of the physical plant at approximately 11:56 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the kitchen/dining room combination, living room and family room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Emergency food pantry in hall closet. Sharps are stored in locked bottom kitchen cabinet. The resident medications stored in locked top kitchen cabinet and observed to be inaccessible to residents. The first aid kit and manual readily accessible on counter below medication storage. There is one (1) fire extinguisher attached to wall in the kitchen and observed to be charged. Laundry room is located adjacent to kitchen. The appliances observed to be functional. Toxins stored above in locked cabinet above washer and dryer was observed to be locked and inaccessible to residents.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HORIZON ASSISTED LIVING FACILITY	FACILITY NUMBER: 197609766
	VISIT DATE: 04/28/2023

NARRATIVE

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(Cont from 809)

The facility has a total of five (5) bedrooms and four (4) bathrooms: One (1) shared and four (4) private bedrooms; three (3) bathrooms for residents use and one (1) bathroom for staff.

The resident bedrooms were properly furnished with at least one chair, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the three (3) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 110.5, 112.6 and 113.5 degrees Fahrenheit.

Backyard has the following: Gazebo with sufficient seating for the residents. Patio furniture observed to be in good repair.

Detached Garage: Used for PPEs and storage.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 12:45 pm, LPA reviewed files for the six (6) residing residents. Resident files included medical assessments and needs and services plans. Staff files reviewed for three (3) staff. Staff files had the appropriate training's to include Dementia, Hospice, and First aid/CPR.

No deficiencies cited.

Exit Interview Conducted / A Copy of the Report Issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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